Monday, 19 March 2012

TUBERCULOSIS: SOUTH AFRICA: What the world's largest preventative TB study taught us

JOHANNESBURG, 13 March 2012 (PlusNews) -

Photo: WHO
Slow implementation of IPT

Even though the world's largest study of preventative tuberculosis therapy indicated that community-wide isoniazid preventative TB therapy (IPT) failed to lower community TB levels among 27,000 South African gold miners, that was not Thibela’s only result. We review some of the others over its seven years:

1. You do not always need an X-ray: In southern Africa, health workers and patients in rural areas often cannot access X-rays to confirm or rule out active pulmonary TB. Without X-rays to verify that patients did not have active TB, many physicians were unwilling to start patients on IPT. Thibela found that health workers could exclude at least 90 percent of active TB cases through sputum testing and symptom screening – asking patients if they were experiencing night sweats, a persistent cough or weight loss. Based in part on these findings, South Africa's latest IPT guidelines issued in June 2010 no longer require chest X-rays and TB skin tests to start HIV-positive patients on IPT.
However, in high TB prevalence settings, researchers noted that chest X-rays increased TB case detection.

2. IPT and HIV: People living with HIV, which compromises the immune system, are up to 37 times more likely to develop active TB. Findings from Thibela were able to confirm what many had long suspected but had failed to prove: that IPT provision to people living with HIV reduced their likelihood of dying. In fact, Thibela researchers showed it halved the risk of death among HIV-positive patients on or just starting antiretrovirals (ARVs). Based on this finding, South African guidelines no longer discourage the use of IPT in ARV patients.

3. Slamming side-effects: Although the World Health Organization had been recommending IPT since 1999, implementation has been slow, partly due to challenges in TB screening and doctors' fears of possible side-effects, most notably liver damage. Thibela researchers, however, found only a small number of cases of liver damage and these were among heavy drinkers. The most commonly reported side-effect of IPT was increased appetite.

4. Ignorance is not always bliss: IPT roll-out has been slow globally but in South Africa, coverage was below 1 percent in 2010 - eight years after the country introduced the preventative therapy. Zambia has only recently begun piloting IPT.
Thibela researchers found that doctors were unwilling to prescribe the drug to patients because they did not know about the drug's TB prevention benefits and did not have experience in prescribing it. Some doctors said they preferred to wait to treat TB with more familiar drug courses than to prevent it.

5. Mobilizing men: Although Thibela eventually included about 27,000 mine workers, mostly men - 80,000 indicated they would be willing to participate in the study. Thibela published research on the community mobilization and education strategies it used to get men on board in a November 2010 supplement of the medical journal, AIDS.
"The uptake we achieved was truly remarkable, especially when you consider it was almost an exclusively male population and men are notoriously poor adopters of health strategies," said Thibela's lead researcher and chief executive officer of South Africa's Aurum Institute for Health, Gavin Churchyard. "We've shown that it is possible to mobilize an entire population to adopt a health prevention strategy."
Strategies that worked well to drive up men's willingness to participate included the use of peer educators, community events and incentives tied to project phases. Less popular were the use of mobile-phone messaging due to frequent phone number changes, and treatment buddies, which sparked privacy concerns among actual trial participants. http://www.plusnews.org/Report/95064/SOUTH-AFRICA-What-the-world-s-largest-preventative-TB-study-taught-us

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After service in the British SAS Regiment the author became a physician and then an orthopaedic surgeon.
He has held professorial positions in Canada, Vietnam and the United States, practiced and taught orthopaedic surgery in three continents and in several wars.
He has extensive experience as an expert witness in court. Somewhere along the way, time was found to operate a four hundred acre mixed farm, a one hundred seat restaurant and to obtain a licence as a flying instructor.
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